1063129880 NPI number — MR. CLARENCE QUENTIN THOMAS COLLINS EMT-P, PA

Table of content: MR. CLARENCE QUENTIN THOMAS COLLINS EMT-P, PA (NPI 1063129880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063129880 NPI number — MR. CLARENCE QUENTIN THOMAS COLLINS EMT-P, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLINS
Provider First Name:
CLARENCE
Provider Middle Name:
QUENTIN THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
EMT-P, PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063129880
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10340 KADUMBA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89178-8019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-708-0570
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10340 KADUMBA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89178-8019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-708-0570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 146N00000X , with the licence number:  0652-4023-4638 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 146L00000X , with the licence number: 0652-4023-4638 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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